Relationships among COVID-19 phobia, health anxiety, and social relations in women living with HIV in Iran: A path analysis

Introduction The COVID-19 pandemic and its consequences have caused fear and anxiety worldwide and imposed a significant physical and psychological burden on people, especially women living with HIV (WLHIV). However, WLHIV were not studied as well as others during the pandemic. Hence, this study aimed to determine the relationships between COVID-19 phobia, health anxiety, and social relations in WLHIV. Materials and methods This cross-sectional study enrolled 300 WLHIV who had records at the Iranian Research Center for HIV/AIDS of Tehran University of Medical Sciences. Data were collected using sociodemographic questionnaire, the fear of COVID-19 scale, the social relations questionnaire, the socioeconomic status scale and the health anxiety inventory. Path-analysis was used to assess the direct and indirct associations between variables. Results Based on the path analysis, among variables that had significant causal relationships with social relations, socioeconomic status (β = -0.14) showed the greatest negative relationship, and health anxiety (β = 0.11) had the strongest positive relationship on the direct path. On the indirect path, fear of COVID-19 (β = 0.049) displayed the greatest positive relationship. The level of education (β = 0.29) was the only variable showing a significant positive relationship with social relations on both direct and indirect paths. Conclusion Our result showed that increased fear and health anxiety related to a higher social relations score in WLHIV. Hence, due to their vulnerability, these people require more support and education to adhere to health protocols in future pandemics and similar situations.

The authors received no specific funding for this work.
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Methods: This descriptive study enrolled 300 PLHIV who had records at the Behavioral Diseases
Center of Tehran University of Medical Sciences. The data were collected via three questionnaires: the Fear of COVID-19 Scale, social relations questionnaire, and sociodemographic information checklist, and analyzed in SPSS 25 and LISREL 8.8.

Conclusion:
This study was conducted during the COVID-19 pandemic when it was necessary to adhere to social distancing and limiting social relations. A better socioeconomic status was related to fewer social relations. Moreover, increased fear and health anxiety related to a higher social relations score. Due to their vulnerability, PLHIV require more support and education to adhere to health protocols.

Background:
The COVID-19 pandemic has affected people's psychological status (Fofana, Latif, Sarfraz, Bashir, & Komal). Based on the Inter-Agency Standing Committee (IASC) report, people are, directly and indirectly, impacted by stressful experiences in this period. The most prevalent responses include fear (of illness, death, loss of livelihood, social isolation, and being quarantined) 3 and fear-related behaviours, e.g., limited social relations, distance from treatment centers, health anxiety, depression, and stress (Porcelli) Fear is an adaptive feeling needed to cope with potential threats, but excessive fear has negative impacts at the personal (mental health issues and anxiety disorders) and social level (seclusion, isolation, xenophobia) (Mertens, Gerritsen, Duijndam, Salemink, & Engelhard). Researchers have discussed the pathological fear of COVID-19 (corona phobia) due to the nature and wide-ranging impacts of the pandemic (Asmundson & Taylor) Various factors may affect the degree of psychological vulnerability to corona phobia, including personal variables such as tolerance, lack of trust, vulnerability to the diseases, anxiety, and concerns (Asmundson & Taylor). Reports suggest that older adults and those with underlying diseases, including HIV, run a greater risk (Control & Prevention). It is expected that the COVID-19 pandemic imposes a more significant physical and psychological burden on people living with HIV (PLHIV) (Chenneville, Gabbidon, Hanson, & Holyfield, 2020;Tunçel et al., 2020). This group lives with severe early death anxiety, different types of fears related to this disease, mental disturbances ranging from indifference and hopelessness to severe reactions such as anxiety and depressive disorders (Belir, Ansari Shahidi, & Mohammadi).
Health anxiety is a wide-ranging cognitive disorder formed as incorrect perceptions about physical changes and symptoms resulting from one's beliefs about illness or health (Solem et al.).
According to some researchers, health anxiety is a major psychological factor related to corona phobia (Asmundson & Taylor). Almost everyone has experienced some degrees of health anxiety, low levels of which are not pathological but rather help people perform and commit to preventive behaviours. However, its severe degrees are associated with maladaptive coping behaviours leading to distress, social incompetence, disrupted job performance, and repeated visits to health centers (Salkovskis & Warwick).

Study Population
The sample size was calculated as 300 following Maria Pizzirusso et al. (Pizzirusso et al.), type I and type II error of 0.05 and 0.2, respectively, and the correlation of 0.16 for social relations and anxiety, by using the following formula:

Inclusion Criteria
Iranian men/women with records at the Behavioral Diseases Center, minimum literacy, absence of mental and physical problems (as reported by the patient/registered in their records) that would preclude them from participation, and no history of psychotropic medications.

Exclusion criteria
Returning incomplete questionnaires, migration, and hospitalization due to COVID-19.

The the Fear of COVID-19 Scale
Pakpour, Griffiths, et al. developed the Fear of COVID-19 Scale in 2020 with seven items (Ahorsu et al.). The responses range from "strongly disagree" (1) to "strongly agree" (5). The sum of scores of all items yields the total score ranging from 7-35. The original version has a Cronbach's alpha of 0.82, test-retest coefficient of 0.88, and appropriate validity. In Iran, its reliability was confirmed with a Cronbach's alpha of 0.86 (Alizadehfard & Alipour). The scale's reliability was confirmed in the current study with a Cronbach's alpha of 0.84.

The Health Anxiety Inventory
The Health Anxiety Inventory was developed by Salkovskis and Warwick (2002)  This questionnaire consists of 11 items scored on a five-point Likert scale from very low to very high (1-5). The score ranges from 11 to 55. Its reliability was confirmed with a Cronbach's alpha of 0.87 (Mousavi, 2013). The current study confirmed its reliability with a Cronbach's alpha of 0.89.

Socioeconomic status scale (SES)
SES consisted of 6 questions, including education of mother and father, income, economic class, and housing status, which are scored based on a Likert scale from 1 to 5, and a total score ranging from 6 to 30. Validity and reliability have been performed in Iran. with a Cronbach's alpha of 0.83 (2013) (Eslami et al.)

Socio-demographic checklist
This scale included questions on the respondents' age, duration of the disease, the number of children, sex partners, education, and having insurance.

Procedure
The study began after obtaining the required permissions and approval from the Ethics Committee of Alborz University of Medical Sciences (IR.ABZUMS.REC.1400.022). The researchers visiting the Behavioral Diseases Centre identified eligible participants and briefed them about the study's objectives. The eligible participants signed a written informed consent form if they were willing to participate. Due to the COVID-19 pandemic and to adhere to distancing and minimal presence at the Center, the questionnaires were sent to those who had Internet access over the Pars Online platform, and they were requested to fill them out in one week. For those who did not have Internet access, a separate room was allocated for filling out the questionnaires. The respondents could ask their questions regarding questionnaire items and resolve any ambiguities by phone for those who used the Internet and in person for those who filled out the questionnaire in the center.
They were all ensured that their data would remain confidential, that participation was not obligatory, and that they would not be deprived of any services if they did not participate.

Statistical analysis 7
This study examined the fitness of a conceptual model for the relationship among fear of COVID-19, health anxiety, and social relations in PLHIV (Figure 1). Path analysis is an extension of conventional regression that shows not only the direct effects but also the indirect effects of each variable on the dependent variables, and the results can be used to provide a rational interpretation of the relationships and correlations observed. Data were analyzed in SPSS-25 and Lisrel-8.8. The results were expressed using Pearson's correlation coefficient for the correlations and in the form of Beta for the path analysis, and the significance level was set at T-value >1.96.

Research Variables
Socio-demographic characteristics included age, education, child number, SES, partner number, disease duration, and having insurance.
Variables used in the path analysis included Age, education, child number, SES, partner number, health anxiety, corona phobia, and social relation.

Results:
The data of 300 PLHIV who had records at the Behavioral Diseases Center of Tehran University of Medical Sciences were investigated. The participants' mean age (39.4 ± 7.5 years), health anxiety score (20.6 ± 7.3), fear of COVID-19 score (22.4 ± 5.3), and social relations score (35.1 ± 3.80 are presented in Table 1. Based on Pearson's correlation analysis, among variables significantly correlated with social relations, education had the strongest significant positive correlation (r ≈ 0.37) and the number of children displayed the strongest significant negative correlation (r ≈ -0.26) ( Table 2).
Based on the path analysis, among variables with significant and causal relationships on the direct path with social relations, socioeconomic status (B = -0.14) had a negative relationship while health anxiety (B = 0.11) had a positive relationship. In other words, with a one-score increase in SES, the social relations score decreased, and with a rise in the health anxiety score, the social relations score increased. On the indirect path, the fear of COVID-19 (B ≈ 0.05) had a significant and positive relationship with social relations; in other words, a rise in fear of COVID-19 score was associated with a rise in social relations score. Level of education was the only variable showing a significant and positive relationship with social relations on both direct and indirect 8 paths (B = 0.29), meaning that a higher level of education was associated with a higher social relations score (Table 3).
The model's fitness indices demonstrate its goodness of fit, and the reasonably adjusted relationships among the variables (Table 4).

Discussion;
This study explored the relationship between fear of COVID-19, health anxiety, and social SES had the highest negative relationship with social relations; the poorer the socioeconomic status, the higher the social relations. On the contrary, other studies reported fewer social relations in lower SES groups. (Vonneilich et al.) In another study, patients with HIV who had a lower SES, were poorer, or had lower living standards had fewer social relations than others. (Zhang, Zhang, Aleong, & Fuller-Thomson) This difference in results can be attributed to the pandemic; in our study, those with a higher SES were less in need of being in the society to earn a living or visit healthcare centers, and these factors limit social relations, especially for PLHIV.
Our study revealed that health anxiety had the greatest positive relationship with social relations.
We found no similar study on patients with HIV regarding this subject. Nonetheless, a possible cause of this finding could be that patients with greater health anxiety repeatedly visit healthcare centers to check their health status. To ensure the diagnosis, they visit different doctors to make sure they are not infected with COVID-19 (Mohammadi & Shahyad, 2020;Solem et al., 2015), which in turn may increase their social relations. The physical signs and symptoms of health anxiety during the pandemic may resemble the signs and symptoms of COVID-19 itself; in this case, people may mistake these physical changes as symptoms of COVID-19. People with high health anxiety regard any physical change as a sign of a disease, which exacerbates their anxiety and concern, and leads to repeated referrals (Mohammadi & Shahyad).

9
People with severe immune deficiencies, such as HIV, face numerous side effects. They may be exposed to severe COVID-19 and have a higher mortality risk due to its complications, all of which can cause or exacerbate their stress and concern. (Shiau, Krause, Valera, Swaminathan, & Halkitis) In the present study, fear of COVID-19 had the strongest positive relationship with social relations through the indirect path. Fear of COVID-19 positively affected health anxiety and thus increased the social relations of the patients. As noted before, PLHIV frequently visit diagnostic and treatment centers due to concerns and fear of COVID-19 complications, which increases their social relations. (Mohammadi & Shahyad, 2020;Solem et al., 2015) COVID-19 research and the media report increased fears of COVID-19. Although fear is a common psychological outcome during the pandemic, it is not limited to morbidity and mortality but may also emerge as social and occupational stress due to the evolving nature of the disease, its prevalence, and its unique risk factors. Corona phobia is a hyper-reactive fear of contracting COVID-19 with three physiologic, cognitive, and behavioural components. Ongoing worry can induce symptoms such as tachycardia, tremor, breathing difficulty, vertigo, a changed appetite, obsession, and affective responses (sadness, guilt, anger). To prevent the consequences, people adopt avoidant behaviours that may disrupt the overall quality of their daily functioning. (Arora, Jha, Alat, & Das) Studies show that the complications and mortality caused by this disease are higher in people with chronic diseases, which induces or exacerbates fear and anxiety in them. (Bakioğlu, Korkmaz, & Ercan, 2021;Mahmoodi & Ghavidel, 2021) In the current study, level of education was the only variable that had significant and positive relationships with social relations on both direct and indirect paths. Likewise, Nojoumi et al.
showed that HIV-positive patients who were educated and employed had a better status than other patients in most quality of life dimensions, especially mental health, social functioning, and environmental dimension. (Nojoomi & Anbari) Educated patients have a better attitude towards the disease and are better adjusted to it due to their better occupational and financial opportunities and high cultural status, which expands their social relations and leads to a better quality of life.
Studies show that people with a higher level of education run a longer and healthier life compared to people of the same age but with a lower level of education. (Zajacova & Lawrence) Contrary to our study, a study in China demonstrated no significant relationship between the social relations 10 of patients with HIV and their level of education. (Liping, Peng, Haijiang, Lahong, & Fan) Cultural differences, economic conditions, and living standards could explain these differences.

Conclusion:
This study was conducted during the COVID-19 pandemic when it was necessary to adhere to social distancing and limiting social relations. A better socioeconomic status was correlated with fewer social relations. Moreover, increased fear and health anxiety correlated with a higher score of social relations. Based on their vulnerability, PLHIV require more support and education to adhere to health protocols.

List of abbreviations:
AGE=age